SECURE CREMATION AND DISPOSITION AUTHORIZATION

This Authorization Form must be completed and signed prior to the cremation. Please read it carefully and ask us any questions you may have. Cremation is an irreversible and final process. It is important that you understand the cremation process that is described in Section 8 of this Authorization Form prior to signing. We want you to fully understand the information provided in this Authorization Form, so we will be happy to answer any questions about the cremation process or any other information in this form. THIS AUTHORIZATION IS NOT A CONTRACT FOR CREMATION SERVICES. A SEPARATE CONTRACT OR CONTRACTS WILL BE REQUIRED TO PURCHASE THE SERVICES OF THE FUNERAL HOME AND/OR CREMATORY.

1. IDENTIFICATION OF THE DECEDENT

Name of Decedent: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Death: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Location of Death: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Age: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Birth: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Social Security Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

BECAUSE CREMATION IS IRREVERSIBLE, IDENTIFICATION OF THE DECEDENT IS REQUIRED BY ONE OF THE FOLLOWING METHODS: (INITIAL ONLY ONE)

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The Authorizing Agent, or personal representative of the Authorizing Agent, has viewed the remains and positively identified them as the
body of the decedent

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The Authorizing Agent or personal representative of the Authorizing Agent has authorized the Funeral Home to photograph or create an
image of the remains and the Authorizing Agent or personal representative has positively identified the photography or image as that of the decedent.

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The Authorizing Agent or personal representative of the Authorizing Agent has identified the decedent's remains by identifying on the remains
or by photograph the following:

Decedant Identifying Attributes: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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2. FUNERAL HOME & CREMATORY

The Authorizing Agent authorizes the Funeral Home & Crematory set forth below to carry out the directions and instructions of the Authorizing Agent contained in the Form.

Funeral Home Name:

Georgia Funeral Care & Cremation Services, Inc.

Funeral Home Address:

4671 S. Main St. Acworth, GA 30101

Crematory Name:

Georgia Funeral Care & Cremation Services, Inc.

Crematory Address:

4671 S. Main St. Acworth, GA 30101

3. AUTHORIZING AGENT – (See below for Order of Authority)

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IDENTIFICATION OF AUTHORIZING AGENT-ORDER OF AUTHORITY (SELECT ONE) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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The Authorizing Agent represents that the relationship between the Authorizing Agent and the Decedent is as follows according to Georgia Law:

4. AUTHORITY OF AUTHORIZING AGENT

As Authorizing Agent, I have reviewed the priority list in #3 (ABOVE) and I represent that I have the right to authorize the cremation of the decedent's remains and I am initialing one of the following four statements below accordingly: (INITIAL ONLY ONE)

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I certify that I do not have actual knowledge of any living person who has a superior right to act as the Authorizing Agent.

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There is another living person(s) listed below who has a superior or equal right to act as the Authorizing Agent. I have made all reasonable efforts to contact such person(s), but have been unable to do so. I have no reason to believe that such person(s) would object to the cremation of the Decedent's remains.

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5. PACEMAKERS, IMPLANTS AD PROSTHESES (SEE BELOW)

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Initial one of the following statements: (Initial Only One)

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The remains of the decedent do not contain any of the devices described as follows: Pacemakers, defibrillators, radioactive implants, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subject to heat. As Authorizing Agent, I have listed in #5 on the reverse side all devices (including mechanical, prosthetic, implants, or materials), which may have been implanted in or attached to the decedent.

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As Authorizing Agent, I instruct the Funeral Home to remove each device listed of above, if possible to remove, and dispose of them as Funeral Home is legally able.

6. CASKET OR ALTERNATIVE CONTAINER

The remains are to be cremated in a combustible casket or alternative container that is capable of being completely closed, is resistant to leakage or spillage, is sufficiently rigid to be handled easily, and provides protection for the health and safety of Crematory and Funeral Home personnel. The Crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event that the casket or container does not meet the above requirements, the Crematory will notify the authorizing Agent. Many caskets are comprised primarily of combustible material also contain some exterior parts (decorative handles or rails) that are not combustible and that may cause damage to the cremation equipment. As Authorizing Agent, I authorize Crematory, in its discretion, to remove and discard the non-combustive materials. I understand that some crematories will not accept metal or fiberglass caskets. I further understand that the casket or alternative container will be consumed as part of the cremation process.

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Cardboard Alternate Container Selected (PROVIDED BY FUNERAL HOME / CREMATORY)

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Casket or Viewing Container Selected: (ADDITIONAL CHARGE MAY APPLY) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

7. WITNESSING CREMATION

Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully release the Funeral Home and Crematory from any liability. To the extent permitted by Crematory, the persons listed on the reverse side are authorized to be present at the cremation room prior to and during the cremation of the Decedent's remains and during the removal of the cremated remains from the cremation chamber. If you desire witnesses, you must initial below and list the witness names. (INITIAL ONLY ONE)

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No Witnessing.

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Yes, the following will witness the cremation (Number is limited and an additional charge may apply) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

8. THE CREMATION PROCESS

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I have read and I understand the following:

The cremation of the Decedent's remains may take place before or after ceremonies to memorialize the Decedent. Cremation is performed to prepare the remains of the Decedent for final disposition. It is carried out by placing the Decedent's remains in the casket or alternative container, which is then placed into a cremation chamber or retort where they are subjected to intense heat and flame. All cremations are performed individually. During the cremation process, it may be necessary to open the cremation chamber and reposition the remains of the Decedent in order to facilitate a complete and thorough cremation. Through the use of a suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them.
Due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as anybody prostheses or dental bridgework) that are left with the remains and not removed from the casket or container prior to the cremation may be destroyed or if not destroyed, will be disposed of by the crematory. The Authorizing Agent understands that arrangements must be made with the Funeral Home to remove any such possessions or valuable prior to the time that the remains of the Decedent are transported to the Crematory.
Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, it is impossible to remove all of them, as some dust and other residue from the process will be left behind. In addition, while every effort will be made to avoid commingling, inadvertent and incidental commingling of minute particles of cremated remains from the residues of a previous cremation is a possibility, and the Authorizing Agent understands and accepts this fact.
After the cremated remains are removed from the cremation chamber, all non-combustible material (in so far as possible) such as denta bridgework and hinges, latches, and nails from the container will be separated and removed from the human bone fragments by visible or magnetic selection. The Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only human bone fragments will remain.
When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless otherwise specified, after the bone fragments have been separated from the other material, they will be mechanically pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as human remains will then be paced into a designated container.

9. AUTHORIZATION TO CREMATE, PROCESS & PULVERIZE

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As Authorizing Agent, I have read and understand the description of the cremation process contained in #8 in this form and authorize the cremation, processing and pulverization of the remains of the Decedent.

10. URN OR TEMPORARY CONTAINER

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Urn selected by Authorizing Agent.

After the cremated remains have been processed, they will be placed in the urn listed on reverse side or, if an urn is not provided to the Crematory, a temporary container will be provided by the Crematory. The Authorizing Agent acknowledges that it is impossible to recover all the dust and residue
from the cremation and processing.

In the case of an adult, it is recommended that the urn or temporary container be a minimum size of 200 cubic inches. In the event the urn or temporary container is insufficient to accommodate all the cremated remains, the excess will be placed by the Crematory in a secondary container. This secondary container will be kept with the urn or temporary container and handled according to the final disposition instruction set forth in section 11, provided, however, that the secondary container may not be designed for shipping. All urns or containers provided to the Funeral Home or Crematory must be appropriate for shipping. The Authorizing Agent directs the Crematory to use the specified urn or container listed in #10.

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Standard temporary container provided by Funeral Home/Crematory (Black plastic box)

11. FINAL DISPOSITION

PLEASE INITIAL THE OPTION SELECTED AFTER READING THE FOLLOWING: (INITIAL ONLY ONE)

Following the Cremation, the Authorizing Agent directs the Crematory and/or Funeral Home to undertake the actions set forth to arrange the final disposition of the cremated remains of the Decedent. If the cremated remains are shipped at any time, the Authorizing Agent directs that the Crematory or Funeral Home utilize the U.S. Postal Service's Priority Mail Express Service with a return receipt or a shipping service that uses an internal system of tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. If shipment by the U.S. Post Office or other deliver company is directed, the Authorizing Agent acknowledges and agrees that there is a risk that the cremated remains could be lost.
The Authorizing Agent understands that if no arrangement for the final disposition, release or shipment of the cremated remains is made in this Authorization, the Crematory or Funeral Home shall hold the cremated remains for sixty (60) days after cremation. If during that sixty (60) day period, the cremated remains are not retrieved by the person designated in this document to receive them or by the Authorizing Agent, or if arrangements for their final disposition are not made, notice will be sent to the Authorizing Agent informing the Authorizing Agent that the cremated remains will be interned or stored if not retrieved in the next thirty (30) days.
Thirty (30) days after the written notice is sent to the Authorizing Agent, if no arrangements for the final disposition of the cremated remains have been made or the Authorizing Agent has not taken delivery of or caused the delivery of the cremated remains, then the Funeral Home may dispose of the cremated remains in a grave or crypt, by storing the cremated remains in the Funeral Home. The authorizing Agent shall be liable for the cost of such final disposition in a grave or crypt and shall reimburse the Funeral Home immediately upon receipt of an invoice.

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Release to Family Member(s) or Representative(s) (PLEASE LIST BELOW) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Deliver To: (FOR ADDITIONAL COST) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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Ship via U.S. Postal Service Priority Mail Express Service: (FOR ADDITIONAL COST) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

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12. PERSONAL PROPERTY

All personal property and effects delivered with the remains of the Decedent to the Funeral Home/Crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, shoes, etc., will be destroyed in the cremation process or otherwise discarded by the crematory, in its sole discretion, unless specific instructions are given by the Authorizing Agent below:

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Instructions for Personal Property: (PLEASE LIST) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

13. VIEWING, VISITATION & FUNERAL CEREMONIES

Prior to the cremation of the Decedent's remains, the Authorizing Agent or decedent's family have arranged for a viewing/ceremony set forth below:

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No Viewing.

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14. TIME OF CREMATION

Please initial one of the following:

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The Crematory may perform the cremation of the decedent's remains at the time and date as its work schedule permits without any further notification to the Authorizing Agent

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The Crematory is to use its best efforts to schedule the cremation in accordance with the schedule set forth below:

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15. CERTIFICATION & INDEMNIFICATION

The Authorizing Agent acknowledges that the Funeral Home and Crematory are relying upon the representations being made by the Authorizing Agent in this Authorization. The Authorizing Agent certifies that all of the information and statements contained in the Authorization are accurate and no omissions of any material fact have been made. The Authorizing Agent agrees to indemnify and hold harmless the Funeral Home and Crematory, their officers, directors, employees and agents from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, including, but not limited to, any legal fees arising out of or resulting from the Funeral Home's and Crematory's reliance on or performance consistent with the directions, statements, representations, and agreements contained in the Authorization.

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